Analysis Navigation in Restricted Waterways The waters of the connecting channels between LakeErie and LakeHuron (including the St.Clair River) constitute a compulsory pilotage area.4 The EvansMcKeil, however, was exempt. The demands on navigating personnel and the workload associated with navigation of the vessel in restricted waterways are high. Given that the pilotage requirements are for the enhancement of safe navigation in Canadian pilotage waters, it is essential that adequate consideration be given to the principles of watch composition with a view to ensuring that the workload is manageable and that all aspects of navigation in confined waterways, including monitoring of the vessel's progress, steering and lookout functions, can be effectively carried out. Watch Composition and Crew Performance There are basic, internationally recognized principles to be observed in keeping a navigational watch and in having proper watch arrangements.5, 6 at no time shall the bridge be left unattended; weather conditions, visibility and whether there is daylight or darkness; proximity of navigational hazards which may make it necessary for the officer in charge of the watch to carry out additional navigational duties; use and operational condition of navigational aids such as radar or electronic position-indicating devices and any other equipment affecting the safe navigation of the ship; whether the ship is fitted with automatic steering; any unusual demands on the navigational watch that may arise as a result of special operational circumstances. at no time shall the bridge be left unattended; weather conditions, visibility and whether there is daylight or darkness; proximity of navigational hazards which may make it necessary for the officer in charge of the watch to carry out additional navigational duties; use and operational condition of navigational aids such as radar or electronic position-indicating devices and any other equipment affecting the safe navigation of the ship; whether the ship is fitted with automatic steering; any unusual demands on the navigational watch that may arise as a result of special operational circumstances. During the course of the voyage of the tug EvansMcKeil and barge OceanHauler, the bridge was crewed by a single person and all of the factors for watch composition were not taken into account. This led to the following degradation in the performance of navigational tasks by a one-person bridge crewing that culminated in the accident. Lookout A separate lookout was not posted, requiring the OOW to assume this added responsibility during nighttime navigation. Given the multitude of tasks the officer was required to carry out, a proper lookout within the context of the Collision Regulations7 was not maintained. When the OOW inadvertently switched the autopilot to the incorrect mode, and then left the bridge, there was no one available to detect the error. Workload The St.Clair River is a narrow waterway that meanders southwestward with many bends, and frequent course changes had to be made during the voyage. In this instance, the first officer was alone on watch and had to contend with the difficulties associated with night navigation. He was engaged in a multitude of tasks that included: verifying the vessel's position on radar, checking the charts, noting the navigational marks being passed, operating the remote steering controller and monitoring the steering of the vessel, and communicating with Vessel Traffic Control (VTC). Consequently, another person qualified to be in charge of the deck watch should have been called at the critical time when the OOWwas contemplating leaving the bridge and a required course change was imminent. Ergonomics and Conduct of Navigation The bridge of the EvansMcKeil is well equipped with electronic navigation equipment including radar and position-indicating devices. However, a review of the ergonomics of the tug and an evaluation of the navigation practices in restricted waterways in use aboard the tug indicated that: the navigation was conducted at night by a single person; the workload associated with watchkeeping duties was high; the watches set were six on/off with no other navigation person readily available. There was no arrangement to relieve the OOW to permit him to meet personal needs such as the use of washroom facilities; and the washroom was not readily accessible to the watchkeeper from the conning position on the upper bridge. This suggests that all of the requirements for watch composition were not fully considered, resulting in the bridge being left unattended at a critical juncture in the vessel's transit and when a course change was imminent. This allowed the tug-barge unit to veer off course, causing damage to shore property and the tug-barge unit to eventually run aground. While the master is responsible for setting up a proper watchkeeping arrangement, it is incumbent upon the owners/operators to ensure that the vessel is crewed with an appropriate number of qualified personnel to safely operate the vessel for the intended voyage taking into account the vessel ergonomics, workload, and overall operational requirements. Similar Occurrences The following occurrences took place in recent years involving such tug-barge units. In each case, one qualified person was alone on the bridge of the tug during night transit within a compulsory pilotage area. At 2230 on 21April2002, the barge PittsCarillon pushed by the tug Progress struck and knocked down Light82 in the St.Lawrence Seaway (TSB report M02C0011). At 0005 on 30April2004, the tug DougMcKeil (with upper and lower wheelhouses), pushing the loaded barge OceanHauler, struck private docks and boathouses on the United States side of the St. Clair River (TSB file M04F0010). At 0555 on 11September2004, the barge A-397, pushed by the tug KarenAndrie (with upper and lower wheelhouses), struck and knocked down Light TowerD33 in the lower Detroit River (TSB report M04C0044). As a consequence of the first mentioned occurrence, the St.Lawrence Seaway Authority (now the St.Lawrence Seaway Management Corporation) announced that the following additional requirements would take effect on 01October2003:8 (c) man the wheelhouse of the ship at all times by either the master or certified deck officer and by another qualified crew member; and (d) have sufficient well rested crew members available for mooring operations and other essential duties. Although these requirements are relevant to all ships including tug and barge units operating within the St.Lawrence Seaway System, the principle, as it applies to safety, equally applies to all vessels operating in any restricted waterways including navigational areas within the Great Lakes and their connecting and tributary waters such as the St.Clair River. Bridge Procedures Manual To assist the navigating officers on the EvansMcKeil, the owners issued a document entitled SMM02 Bridge Procedures, which is an extract from their Safety Management Manual. Much of the document reiterates the basic, internationally recognized principles to be observed in keeping a navigational watch and in having proper watch arrangements. However, given the complement of the vessel and the structuring of the bridge watch by one qualified person, the relevant bridge procedural requirements could not be fully met. The officer of the watch (OOW) inadvertently switched the autopilot to the incorrect mode and then left the bridge unattended, allowing the tug-barge unit to veer off course, cause damage to shore property, and eventually run aground. The transit took place in darkness without a dedicated lookout. Another person qualified to be in charge of a deck watch was not called at a critical time when the OOW needed to leave the bridge and a required course change was imminent.Findings as to Causes and Contributing Factors The officer of the watch (OOW) inadvertently switched the autopilot to the incorrect mode and then left the bridge unattended, allowing the tug-barge unit to veer off course, cause damage to shore property, and eventually run aground. The transit took place in darkness without a dedicated lookout. Another person qualified to be in charge of a deck watch was not called at a critical time when the OOW needed to leave the bridge and a required course change was imminent. Safety Action Taken McKeil Marine Limited McKeil Marine Limited took the following safety action: At all times while navigating in confined waters or reduced visibility or any other time when deemed necessary, there must be two qualified personnel in the wheelhouse. The qualified personnel must be a minimum of one licensed navigating officer and one duly qualified bridge watchkeeper. This policy must be strictly adhered to at all times. This notice was updated in 2006 as Company Standing Orders (Bridge), and now states in part: When navigating in rivers, canals or sheltered waters, the wheelhouse shall be manned by at least two persons (a certified navigating officer and the other having a Bridge Watchman certificate/trainee). The vessel shall be on hand steering (autopilot shall NOT be used) when navigating in rivers, canals or sheltered waters, areas of heavy traffic, poor visibility and during other hazardous navigational situations. When the vessel is underway, the wheelhouse shall NOT be left unmanned at any time. When navigating in rivers, canals or sheltered waters, the wheelhouse shall be manned by at least two persons (a certified navigating officer and the other having a Bridge Watchman certificate/trainee). The vessel shall be on hand steering (autopilot shall NOT be used) when navigating in rivers, canals or sheltered waters, areas of heavy traffic, poor visibility and during other hazardous navigational situations. When the vessel is underway, the wheelhouse shall NOT be left unmanned at any time. Although the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code) does not apply to the EvansMcKeil, the company is in the process of revising its current Safety Management Manual (SMM), which will result in the creation of a standardized version to be used by all vessels in its fleet, and with the intention of becoming voluntarily ISM-compliant. In the interim, the EvansMcKeil was provided with a Bridge Procedures Manual (Section7.2 of the SMM), which is updated on an ongoing basis. Transport Canada Transport Canada formed a Tug and Barge Working Group, comprising government and stakeholder representatives. This working group provides a forum for detailed discussion on regulatory and operational matters relating to the Canadian tug and barge industry. Two of the priorities address the development of a comprehensive set of standards/regulations dealing with the operation and construction of combination tug/barge systems, and the development of common definitions for the purposes of lighting requirements under the Collision Regulations.